Options Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
I authorize Options Counseling & Family Services to use and disclose a copy of the specific health information described below regarding:
Name of Individual: DOB:
Options Location: Options Counseling and Family Services Location: Beaverton - 8285 SW Nimbus Ave, Ste 148; Beaverton, OR 97008 Fax: (503)352-3262Clackamas - 12901 SE 97th Ave, Ste 340; Clackamas, OR 97015 Fax: (503)655-6806Eugene - 1255 Pearl St, Ste 102; Eugene, OR 97401 Fax: (541)687-2063Florence - 1445 8th St; Florence, OR 97439 Fax: (541)997-8606Multnomah - 11010 SE Division St, Ste 202; Portland, OR 97266 Fax: (503)335-5974Newport - 119 NE 4th St; Newport, OR 97365 Fax: (541)264-7515North Salem - 2645 Portland Road NE, Ste 120; Salem, OR 97301 Fax: (503)393-3135Roseburg - 283 SE Fowler St, Ste 2; Roseburg, OR 97470 Fax: (541)464-6457South Salem - 1515 Liberty St SE; Salem, OR 97302 Fax: (503)468-3130Springfield - 175 West B St, Bldg D; Springfield, OR 97477 Fax: (541)762-1974St. Helens - 445 Port Ave, Ste C; St. Helens, OR 97051 Fax: (503)335-5974Woodburn - 1320 Meridian Dr; Woodburn, OR 97071 Fax: (503)498-5810
My information may be released to or from the following Agency or Name of Individual : Address: Phone : Fax :
If the information to be disclosed contains any of the types of records or information listed below, additional laws relating to the use and disclosure of the information may apply. Information used or disclosed on this authorization may be subject to redisclosure and could no longer be protected by federal and state laws on use and disclosure. I understand and agree that this information will be disclosed if I place my initials in the applicable space next to the type of information. Initial each documentation category you are authorizing.
Drug/Alcohol diagnosis, Treatment or referral Information : HIV/AIDS Information : Genetic Testing : Mental Health Information:
For the purpose of: Legal Care Coordination Other Items not to be included:
You do not need to sign this authorization. Refusal to sign the authorization will not adversely affect your ability to receive health care services or reimbursement for services. The only circumstance when refusal to sign means you will not receive health care services is if the health care services are solely for the purpose of providing health information to someone else and the authorization is necessary to make that disclosure.
You may revoke this authorization in writing at any time. If you revoke your authorization, the information described above may no longer be used or disclosed for the purposes described in this written authorization. The only exception is when a covered entity has taken action in reliance on the authorization or the authorization was obtained as a condition of obtaining insurance coverage. To revoke this authorization, send a written statement to:Options Medical Records, 3500 Chad Dr. #350, Eugene OR 97408.
Clients 14 years of age and older may sign and authorize their own authorizations to release information. Authority : Self Parent / Guardian Legal Custodian Legal Custodian Description of personal representative ’s Guardian Other, as listed
To those receiving information under this authorization: The information disclosed to you is protected by state and federal law. You are not authorized to release it to any agency or person not listed on this form without specific written consent of the person to whom it pertains unless authorized by other laws.
I have read this authorization and I understand it Unless revoked, this release will expire
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Your legal name
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If you have questions about the contents of this document, you can email the document owner.
Document Name: Options Counseling AUTHORIZATION TO USE AND DISCLOSE PROTECTED HEALTH INFORMATION
Agree & Sign